Benedicte Carlsen

What about N? A methodological study of sample-size reporting in focus group studies

BackgroundFocus group studies are increasingly published in health related journals, but we know little about how researchers use this method, particularly how they determine the number of focus groups to conduct. The methodological literature commonly advises researchers to follow principles of data saturation, although practical advise on how to do this is lacking. Our objectives were firstly, to describe the current status of sample size in focus group studies reported in health journals. Secondly, to assess whether and how researchers explain the number of focus groups they carry out.MethodsWe searched PubMed for studies that had used focus groups and that had been published in open access journals during 2008, and extracted data on the number of focus groups and on any explanation authors gave for this number. We also did a qualitative assessment of the papers with regard to how number of groups was explained and discussed.ResultsWe identified 220 papers published in 117 journals. In these papers insufficient reporting of sample sizes was common. The number of focus groups conducted varied greatly (mean 8.4, median 5, range 1 to 96). Thirty seven (17%) studies attempted to explain the number of groups. Six studies referred to rules of thumb in the literature, three stated that they were unable to organize more groups for practical reasons, while 28 studies stated that they had reached a point of saturation. Among those stating that they had reached a point of saturation, several appeared not to have followed principles from grounded theory where data collection and analysis is an iterative process until saturation is reached. Studies with high numbers of focus groups did not offer explanations for number of groups. Too much data as a study weakness was not an issue discussed in any of the reviewed papers.ConclusionsBased on these findings we suggest that journals adopt more stringent requirements for focus group method reporting. The often poor and inconsistent reporting seen in these studies may also reflect the lack of clear, evidence-based guidance about deciding on sample size. More empirical research is needed to develop focus group methodology.

Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADE-CERQual).

Simon Lewin and colleagues present a methodology for increasing transparency and confidence in qualitative research synthesis.

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction

Objective  This study investigates general practitioners’ (GPs) and patients’ attitudes to shared decision making, and how these attitudes affect patient satisfaction.

Introduction of the patient-list system in general practice. Changes in Norwegian physicians' perception of their gatekeeper role.

Objective – To explore whether the patient-list system, recently introduced in general practice, has influenced general practitioners’ (GPs’) self-perception as gatekeepers. Design – Structured focus group interviews with GPs and a short self-administered questionnaire. Setting – Primary care within the public health care system in Norway. Group interviews were conducted 6 months to 1 year after the patient-list system was introduced in June, 2001. Subjects – 81 GPs attending tutorial groups or specialists’ continuous education groups. Outcome measures – GPs’ experience with the reform as stated in 11 group discussions, recorded, transcribed and systematically analysed through coding and extracting of the informants’ statements. The questionnaire provided background information about each participant. Results – The doctors generally perceived themselves as less concerned with the gatekeeper role under the new system. They felt it more important to provide better services and keep patients satisfied. The practitioners explained this shift using three contextual factors: increased and more visible competition, higher expectations from the patients and more responsibility assigned to the GP. Conclusion – GPs in Norway have experienced a shift in power in the physician–patient relationship favouring the patient. The GPs consciousness of the gatekeeper role has diminished. We question whether the new system lessens the incentive to consider resource use in decision-making.

Attitudes to clinical guidelines—do GPs differ from other medical doctors?

Background Clinical guidelines are important for ensuring quality of treatment and care. For this reason, it is essential that clinicians adhere to guidelines. Review studies conclude that barriers to using guidelines are context specific. Nevertheless, there is a lack of studies that compare the attitudes of different groups of doctors to guidelines. Objectives To survey the attitudes of Norwegian medical practitioners to clinical guidelines and the reasons for any scepticism, and to compare general practitioners (GPs) with other medical doctors in Norway in this respect. Method Postal questionnaire to a panel of 1649 Norwegian medical doctors. Results 1072 doctors responded (65%). 97% claimed to be familiar with and following guidelines. A majority expressed confidence in guidelines issued by the health authorities and the medical association. GPs are significantly more uncertain about the legal status of, accessibility of and evidence in guidelines than other doctors. The most important barriers to guideline adherence are concerns about the uniqueness of individual cases and reliance on ones own professional discretion. Both groups rank attitudinal constraints higher than practical constraints, but GPs more often report practical issues as reasons for non-adherence. Conclusion It is suggested that creating trust in guidelines could be more important than more efforts to improve guideline format and accessibility. It may also be worth considering whether guidelines should be implemented using different processes in generalist and specialist care.

Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series

The GRADE-CERQual (‘Confidence in the Evidence from Reviews of Qualitative research’) approach provides guidance for assessing how much confidence to place in findings from systematic reviews of qualitative research (or qualitative evidence syntheses). The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. Confidence in the evidence from qualitative evidence syntheses is an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. CERQual provides a systematic and transparent framework for assessing confidence in individual review findings, based on consideration of four components: (1) methodological limitations, (2) coherence, (3) adequacy of data, and (4) relevance. A fifth component, dissemination (or publication) bias, may also be important and is being explored. As with the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach for effectiveness evidence, CERQual suggests summarising evidence in succinct, transparent, and informative Summary of Qualitative Findings tables. These tables are designed to communicate the review findings and the CERQual assessment of confidence in each finding. This article is the first of a seven-part series providing guidance on how to apply the CERQual approach. In this paper, we describe the rationale and conceptual basis for CERQual, the aims of the approach, how the approach was developed, and its main components. We also outline the purpose and structure of this series and discuss the growing role for qualitative evidence in decision-making. Papers 3, 4, 5, 6, and 7 in this series discuss each CERQual component, including the rationale for including the component in the approach, how the component is conceptualised, and how it should be assessed. Paper 2 discusses how to make an overall assessment of confidence in a review finding and how to create a Summary of Qualitative Findings table. The series is intended primarily for those undertaking qualitative evidence syntheses or using their findings in decision-making processes but is also relevant to guideline development agencies, primary qualitative researchers, and implementation scientists and practitioners.

Professional support of self-help groups: a support group project for Chronic Fatigue Syndrome patients

Professionals are involved in self-help groups in a variety of roles as advising experts, facilitators and even as group leaders. A few studies focus on attitudes toward professional involvement, but very little is known about the nature of this collaboration. The study follows a collaborative support group project between a team of health professionals at a regional hospital in Norway and a Chronic Fatigue Syndrome patients’ group. It is arguably an advantage for professionals to decide upon the aim of a joint intervention in dialogue with the participants, but simply asking the participants what their aims are does not guarantee actual agreement. As this case study demonstrates, participants may have reason to conceal their objectives.

Applying GRADE-CERQual to qualitative evidence synthesis findings—paper 2: how to make an overall CERQual assessment of confidence and create a Summary of Qualitative Findings table

BackgroundThe GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision making, including guideline development and policy formulation.CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on making an overall assessment of confidence in a review finding and creating a CERQual Evidence Profile and a CERQual Summary of Qualitative Findings table.MethodsWe developed this guidance by examining the methods used by other GRADE approaches, gathering feedback from relevant research communities and developing consensus through project group meetings. We then piloted the guidance on several qualitative evidence syntheses before agreeing on the approach.ResultsConfidence in the evidence is an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. Creating a summary of each review finding and deciding whether or not CERQual should be used are important steps prior to assessing confidence. Confidence should be assessed for each review finding individually, based on the judgements made for each of the four CERQual components. Four levels are used to describe the overall assessment of confidence: high, moderate, low or very low. The overall CERQual assessment for each review finding should be explained in a CERQual Evidence Profile and Summary of Qualitative Findings table.ConclusionsStructuring and summarising review findings, assessing confidence in those findings using CERQual and creating a CERQual Evidence Profile and Summary of Qualitative Findings table should be essential components of undertaking qualitative evidence syntheses. This paper describes the end point of a CERQual assessment and should be read in conjunction with the other papers in the series that provide information on assessing individual CERQual components.

Psychiatry out-of-hours: a focus group study of GPs' experiences in Norwegian casualty clinics

BackgroundFor Norwegian general practitioners (GPs), acute treatment of mental illness and substance abuse are among the most commonly experienced emergency situations in out-of-hours primary healthcare. The largest share of acute referrals to emergency psychiatric wards occurs out-of-hours, and out-of-hours services are responsible for a disproportionately high share of compulsory referrals. Concerns exist regarding the quality of mental healthcare provided in the out-of-hours setting. The aim of this study was to explore which challenges GPs experience when providing emergency care out-of-hours to patients presenting problems related to mental illness or substance abuse.MethodsWe conducted a qualitative study based on two individual interviews and six focus groups with purposively sampled GPs (totally 45 participants). The interviews were analysed successively in an editing style, using a thematic approach based on methodological descriptions by Charmaz and Malterud.ResultsSafety and uncertainty were the dominating themes in the discussions. The threat to personal safety due to unpredictable patient behaviour was a central concern, and present security precautions in the out-of-hours services were questioned. The GPs expressed high levels of uncertainty in their work with patients presenting problems related to mental illness or substance abuse. The complexity of the problems presented, shortage of time, limited access to reliable information and limited range of interventions available during out-of-hours contributed to this uncertainty. Perceived access to second opinion seemed to have a major impact on subjectively experienced work stress.ConclusionsThe GPs experienced out-of-hours psychiatry as a field with high levels of uncertainty and limited support to help them meet the experienced challenges. This might influence the quality of care provided. If the current organisation of emergency mental healthcare is to be kept, we need to provide GPs with a better support framework out-of-hours.

The Last Frontier?: Autonomy, Uncertainty and Standardisation in General Practice

Abstract Earlier studies, mainly based in the UK, the US, Canada and the Netherlands, indicate that GPs are reluctant to follow guidelines. This study explores the rationale behind GPs’ reluctance to follow guidelines through focus group interviews with Norwegian GPs. A central concern appearing in the interviews is the GPs’ notion of professional identity. The GP was identified as an autonomous generalist with a close alliance to the patient and a sceptical distance to academic medicine and health authorities. Guidelines are seen to conflict with the GPs’ sense of clinical autonomy. Another aspect discussed by the GPs was an authority-based clinical insecurity which made them sceptical about the evidence. The findings highlight the need to ground the debate about standardisation of practice in the practitioners’ professional identity. The study also underlines the importance of transparency in the standardisation process.